CEO SUMMARY: In the Northeast, the microbiology department of a four-hospital health system adopted new technology for testing patients suspected of sepsis. Not only did this microbiology lab shorten the time-to-detection, it increased the diagnosis rate for sepsis from 9% to 15%—an improvement in detection of 67%! This effort led to shorter patient stays, improved patient outcomes, and the ability to code more accurately for sepsis, thus increasing revenue for the health system by $1.7 million.
AS LAB BUDGETS SHRINK, it becomes essential for pathologists and laboratory directors to demonstrate how clinicians can use clinical lab tests to deliver more value—in the form of improved patient outcomes and lower cost per healthcare encounter.
One opportunity for the hospital lab to deliver substantial added value is in the diagnosis and treatment of sepsis. Time to treat is the critical parameter for patients with sepsis because any patient showing signs of septicemia needs immediate treatment. To treat these patients optimally, clinicians need to identify the pathogen causing the infection so they can choose the most appropriate medication.
Even before they know which pathogen is causing the infection, physicians often prescribe a broad spectrum antibiotic. They do so because it typically requires many hours or days before the microbiology laboratory can definitively identify the infectious agent. These agents can include bacteria, yeast, and fungi. Of great concern is the fact that 35% to 70% of sepsis cases result in patient death.
At New York Presbyterian Columbia University Medical Center (NYP/CUMC) in New York City, the microbiology laboratory is implementing specific innovations to improve diagnostic accuracy and shorten the time-to-answer for patients suspected of having sepsis. To achieve this, the lab needs to develop solutions to address several unique aspects of the patient population it serves.
This effort is led by Susan Whittier, Ph.D., ABMM. She is the Associate Director, Clinical Microbiology Service at NYP/CUMC. “Having a positive identification of sepsis not only improves patient care,” she stated, “but can also increase hospital revenue in ways that I will explain.”
75,000 Blood Cultures Yearly
In the medical center’s Clinical Microbiology Service, Whittier’s laboratory is comprised of 50 technologists. They staff the service 24 hours a day, seven days a week. This microbiology laboratory analyzes more than 75,000 blood cultures annually from three hospitals.
Whittier’s keen interest in sepsis testing started before she joined the staff at New York Presbyterian/Columbia University Medical Center. Previously, Whittier worked in a four-hospital system in New Jersey. There she studied methods of sepsis testing that included the BAC TEC Plus Aerobic medium, a blood culture product from Becton, Dickinson Diagnostics (BD). During her years at this health system, Whittier found this culture medium to be more effective in helping clinicians to identify sepsis than other testing methods.
Whittier believes a clinical study published March 15 in the journal, Clinical Infectious Diseases, confirms her experience in New Jersey. Titled “Comparison of 2 Blood Culture Media Shows Significant Differences in Bacterial Recovery for Patients on Antimicrobial Therapy,” it involved almost 9,400 blood cultures. (See http://cid.oxfordjournals.org/content/56/6/679.)
Early Results Confirmed
“This study is exciting because it shows the tremendous potential to identify— within hours—the specific infectious agents that are in a blood culture,” she said. “One key finding from this study is that it shows the value of using resin as a medium versus non resin.
“For 15 years, clinical researchers have been using in vitro methods to demonstrate the benefit of resin,” observed Whittier. “While in vitro data has consistently shown that the resin system is better than the non-resin system, clinical correlation was lacking. What is different about this study is the large number of patients, almost 10,000, and the use of clinical parameters that are different from those used in prior studies.”
The new study shows how early treatment with broad-spectrum antibiotics can negatively affect clinicians’ ability to detect bacteria in blood samples from potentially septic patients, according to a report on the study in Infection Control Today.
The research also demonstrated the importance of antimicrobial removal systems, such as the BAC TEC resin, to quickly and accurately detect the pathogens. In turn, this aids physicians in making treatment decisions about which therapies to use for patients suspected of having septicemia, Infection Control Today reported.
Significant Study Findings
“The fact that the resin-based system was fast and accurate at recovering bacteria from patients who were already treated with antimicrobials is significant,” explained Whittier. “This is because many patients suspected of having sepsis often are treated with broad spectrum antibiotics before clinicians have a positive identification of the pathogen.
“At our hospital, located in the Washington Heights neighborhood of Manhattan, we regularly have a significant proportion of our patients show up at the hospital on inappropriate antibiotics,” she continued. “Yes, this happens everywhere. But in this neighborhood, patients can get antibiotics over the counter from local bodegas. That is what happens in the Dominican Republic which is where our patients are from, so that’s what happens here.
“Also, when patients suspect they have an infection, they may have antibiotics from an earlier prescription,” noted Whittier. “Those antibiotics may or may not be useful to them by the time they arrive in our emergency department.
“These are the reasons why these antimicrobial removal devices are so important to our microbiology department,” she said. “Our laboratory needs to identify the pathogen regardless of what antibiotics the patient has been taking.
“We’ve made inroads at improving both the time-to-answer and the accuracy of diagnosing sepsis,” she added. “This contributes to improved patient outcomes. It also helps add revenue for the hospital.
“It happens because, once the hospital has a positive diagnosis, it can bill for the higher amount allowed under the DRG for sepsis,” stated Whittier. “By contrast, if the case is coded as an ‘infection of unknown origin,’ the DRG is not as high and the difference can be several thousand dollars in lower reimbursement.
“While working with the four-hospital system in New Jersey, the microbiology department recommended replacing the routine media for sepsis identification with media containing the resin,” she recalled. “However, the resin was a bit more expensive and we needed to justify the increased costs within the lab.
“The change in outcomes was rather dramatic,” continued Whittier. “As a result of using the resin media at the four hospital labs sending samples to our core lab, we saw the positive blood culture rate increase from 9% to 15%! Then, to examine the financial effect of the increased blood culture rate, we looked at the DRG data.
Increased Rate of Detection
“At three separate hospitals, the DRG coding for sepsis went up by 40% to 50% as a direct consequence of our microbiology laboratory identifying more positive blood cultures,” she noted. “This had two measurable benefits.
“First, by providing clinicians with a faster and more accurate answer, the length of stay for sepsis patients was reduced,” stated Whittier. “When clinicians had the correct diagnosis, they could treat these patients with the appropriate medication and get them home sooner.
“Second, revenue associated with the appropriate DRG for sepsis increased by about $1.7 million,” she said. “That’s significant. It demonstrated that spending a little extra for lab testing could deliver both improved patient outcomes and a favorable increase in the parent hospitals’ revenues.”
Since her arrival at NYP/CUMC, Whittier has laid the groundwork to launch a similar program. “We have implemented resin-based blood culture bottles here as well,” observed Whittier. “As a bigger and more complex medical center, analyzing the data is a bit more complicated.
“However our initial review supports my past findings,” she said. “Use of resins when testing for sepsis can optimize patient management, and the financial implications for the medical center are significant as well. It is a win-win situation for the patient and our bottom line.”
More Attention on Sepsis Creates Lab Opportunities
SEPSIS IS THE MOST COMMON KILLER in intensive care units, according to experts on this systemic infection. The death rate from sepsis is higher than that of breast cancer, lung cancer, and stroke combined, according to one researcher.
Worldwide, hospitalizations for sepsis more than doubled in the past 10 years, according to the European Society of Intensive Care Medicine (ESICM). Our sister publication, DarkDaily.com, issued an e-briefing on February 11 on the action by New York State to implement tougher standards for the diagnosis and treatment of hospitalized patients with sepsis. Under the new requirements, which have yet to be published, physicians must become faster at making an accurate diagnosis of sepsis. This development was announced by New York Governor Andrew M. Cuomo in his State of the State message in January.
The New York Times reported that, once the regulations are published, New York will be the first state in the nation to require hospitals to take aggressive steps to manage patients suspected of having sepsis so that treatment can begin sooner. Hospitals in New York must adopt new procedures to identify sepsis, including using a countdown clock to begin treatment within an hour of diagnosis.